\documentclass[10pt]{report}
\usepackage[scaled=0.92]{helvet}
\usepackage{multirow}
\usepackage{hyperref}
\usepackage{graphicx}

\begin{document}
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\begin{center}
  \begin{tabular}{p{0.5\textwidth} p{0.5\textwidth}}
    \includegraphics[width=4cm]{wraplogo} \newline
%    \includegraphics[width=4cm]{UA-1C-SOLID} \newline
%    \includegraphics[width=3cm]{SOLIDlogo.png} \newline
    {\small Faculty of Graduate Studies and Research} \newline
    {\tiny KILLAM CENTRE FOR ADVANCED STUDIES} \newline
    {\tiny 2-29 TRIFFO HALL}  
    &
    {\Large  University of Alberta \newline  Library Release }
    \\
  \end{tabular}
\end{center}
\vspace{0.5cm}

\begin{Form}

  \begin{center}
    \begin{tabular}{ll}
      \multirow{2}{*}{Name of Author:}  &  
      \multirow{2}{*}{\TextField[maxlen=30,width=5cm,name=name,align=0]{}} \\ \\
      \multirow{2}{*}{UofA ID Number:}  &  
      \multirow{2}{*}{\TextField[maxlen=30,width=5cm,name=idnum,align=0]{}} \\ \\
      Title of Thesis: &  
      \multirow{4}{*}{\TextField[maxlen=600,name=title,width=5cm,height=1.5cm,align=0,multiline=true]{}} \\ \\ \\ \\
      \multirow{2}{*}{Degree:} &
      \multirow{2}{*}{\TextField[maxlen=30,width=5cm,name=degree,align=0]{}} \\\\
      \multirow{2}{*}{Year Degree Granted:} & 
      \multirow{2}{*}{\TextField[maxlen=30,width=5cm,name=year,align=0]{}}  \\\\
    \end{tabular}
  \end{center}
\end{Form}

{\small
Permission is hereby granted to the University of Alberta Library to
reproduce single copies of this thesis and to lend or sell such copies
for private, scholarly or scientific research purposes only. Where the
thesis is converted to, or otherwise made available in digital form,
the University of Alberta will advise potential users of the thesis of
these terms.  

The author reserves all other publication and other rights in
association with the copyright in the thesis and, except as herein
before provided, neither the thesis nor any substantial portion
thereof may be printed or otherwise reproduced in any material form
whatsoever without the author's prior written permission.
}

\vspace{1cm}
\begin{center}
  \begin{tabular}{p{0.5\textwidth} p{0.5\textwidth}}
    \underline{\hspace{5cm}} &  \underline{\hspace{3cm}}\\
    Signature & Date \\
  \end{tabular}
\end{center}


\noindent
\parbox{\textwidth}
{\tiny Personal information on this form is collected under the
  authority of Section 33(c) of Alberta’s Freedom of Information and
  Protection of Privacy Act for authorized purposes including
  admission and registration; administration of records, scholarships
  and awards, student services; and university planning and
  research. Students’ personal information may be disclosed to
  academic and administrative units according to university policy,
  federal and provincial reporting requirements, data sharing
  agreements with student governance associations, and to contracted
  or public health care providers as required. For details on the use
  and disclosure of this information call the Faculty of Graduate
  Studies and Research at 492-3499 or see www.ualberta.ca/FOIPP. 
}

\end{document}

